Healthcare Accreditation for Dental Practices What is accreditation Accreditation is independent recognition that the Dental Practice meets the requirements of defined criteria or standards This is a recognised evaluation process used to assess the quality of care and services provided in a range of areas including oral health care Accreditation is one tool which can be used to improve safety and quality in a dental practice It is a way of verifying actions are being taken system data and information is being used to inform activity and Safety and quality improvement is being achieved ACCREDITATION IS RECOGNISED AS AN IMPORTANT DRIVER FOR SAFETY AND QUALITY IMPROVEMENT Dental Business Masters Dr Sameer Bhandari 2

Goals of accreditation Accreditation will help monitor and improve the performance of the Dental Practice and communicate the importance of patient experience and quality management to all dentists This will promote the patient s confidence in dental professionals and improve patient protection Accreditation of practice will help set standards of Dental Practice and conduct The primary goal is to protect the public from harm and to improve the quality of health service provision Specific goals include the following Formulate mandatory guidelines that dental clinics must follow Conduct unbiased individual peer reviewed assessment of functioning of all dental clinics Establish benchmarks for dental health care delivery Continually upgrade the dental clinics by regular assessment of existing norms The principal purpose of accreditation is to protect the health and safety of the public by ensuring that oral healthcare practitioners remain fit and competent to practice within a defined scope of practice throughout their working lives Dental Business Masters Dr Sameer Bhandari 3

CLINICAL STANDARDS Access Assess continuity of Care Clinical standards under this category are set with the following intention a Patients are well informed of the services that the practice provides This will facilitate in appropriately matching patients with the Practice s resources Only those patients who can be cared for by the practice are registered b Emergency patients receive life stabilizing treatment and are then either admitted If resources are available or transferred appropriately to a health care provider that has the resources to take care of such patients c Out patients who do not match the practice s resources are similarly referred to providers that have the matching resources d Patients that match the practice s resources are registered using a defined process e Patients cared for by the practice undergo an established initial assessment and periodic and regular reassessments f Assessments include planning for utilization of laboratory and imaging services Dental Business Masters Dr Sameer Bhandari 5

g The laboratory and imaging services are provided by competent staff in a safe environment for both patients and staff h These assessments result in formulation of a definite plan of care i Patient care is multidisciplinary in nature and encourages continuity of care through well defined transfer and discharge protocols j These protocols include transfer of adequate information with the patient Dental Business Masters Dr Sameer Bhandari 6

Care of Patients Clinical standards under this category are set with the following intention a The practice provides uniform care to all patients in different settings b The different settings include care provided in outpatient units various categories of wards intensive care units procedure rooms and operation theatre c When similar care is provided in these different settings care delivery is uniform d Policies procedures applicable laws and regulations guide emergency and ambulance services cardio pulmonary resuscitation use of blood and blood products care of patients in the Intensive care and high dependency units e Policies procedures applicable laws and regulations also guide care of vulnerable patients elderly physically and or mentally challenged and children high risk obstetrical patients paediatric patients patients undergoing moderate sedation administration of anaesthesia patients undergoing surgical procedures patients under restraints research activities and end of life care f Pain management nutritional therapy and rehabilitative services are also addressed with a view to provide comprehensive health care g The standards aim to guide and encourage patient safety as the overall principle for providing care to patients Dental Business Masters Dr Sameer Bhandari 7

Patients rights education Clinical standards in this category are set with the following intention a The Dental Practice defines the patient and family rights and responsibilities b The staff is aware of these and is trained to protect patient rights c Patients are informed of their rights and educated about their responsibilities at the time of admission d They are informed about the disease the possible outcomes and are involved in decision making e The costs are explained in a clear manner to patient and or family f The patients are educated about the mechanism available for addressing grievances g A documented process for obtaining patient and or families consent exists for informed decision making about their care h Patients and families have a right to information and education about their healthcare needs in language and manner that is understood by them Dental Business Masters Dr Sameer Bhandari 8

Management of Materials Medicaments Clinical standards in this category are set with the following intention a The practice has a safe and organized medication process The process includes policies and procedures that guide the availability safe storage prescription dispensing and administration of medications b The standards encourage integration of the pharmacy into everyday functioning of hospitals and patient care c The pharmacy should guide and audit medication processes d The pharmacy should have oversight of all medications stocked out of the pharmacy e The pharmacy should ensure correct storage as regards to temperature look alike sound alike etc expiry dates and maintenance of documentation f The availability of emergency medication is stressed upon g The practice should have a mechanism to ensure that the emergency medications are standardized throughout the practice readily available and replenished in a timely manner h There should be a monitoring mechanism to ensure that the required medications are always stocked and well within expiry dates Dental Business Masters Dr Sameer Bhandari 9

i Every high risk medication order should be verified by an appropriate person so as to ensure accuracy of the dose frequency and route of administration The appropriate person could be another doctor trained nurse or preferably a clinical pharmacist j Such a person would also look for drug drug Interactions renal or hepatic dosing etc k There should be a mechanism by which this person could verify the order with prescriber in case of doubts or clarification and then make changes to the order after such clarifications l The verification should occur before the medication i e administered but preferably prior to dispensing of the medication there should be a protocol by way of which in case of continued conflict the person can approach higher authority to ensure patient safety m The process also includes monitoring of patients after administration and procedures for reporting and analysing medication errors Safe use of high risk medication like narcotics chemotherapeutic agents and radioactive isotopes are guided by policies and procedures n Patients and family members are educated about safe medication and fooddrug Interactions o Medications also include blood implants devices and medical gases Dental Business Masters Dr Sameer Bhandari 10

Infection Control Clinical standards in this category are set with the following intention a The standards guide the provision of an effective infection control programme in the Dental Practice b The programme is documented and aims at reducing or eliminating infection risks to patients visitors and providers of care c The Dental Practice measures and takes action to prevent or reduce the risk of Healthcare Associated Infection HAI in patients and employees d The Dental Practice provides proper facilities and adequate resources to support the Infection Control Programme e The programme includes an action plan to control outbreaks of infection disinfection sterilization activities biomedical waste BMW management and training of staff and employee health Dental Business Masters Dr Sameer Bhandari 11

NON CLINICAL STANDARDS Continual Quality Improvement Non Clinical standards in this category are set with the following intention a The standards encourage an environment of continual quality improvement b The quality and safety programme should be documented and involve all areas of the Dental Practice and all staff members c The Dental Practice should collect data on structures processes and outcomes especially in areas of high risk situations d The collected data should be collated analysed and used for further improvements e The improvements should be sustained f The quality programme of the diagnostic services should be integrated into the dental practice s quality plan g Infection control and patient safety plans should also be integrated into the dental practice s quality plan h The Dental Practice should define its sentinel events and intensively investigate when such events occur i The quality programme should be supported by the management Dental Business Masters Dr Sameer Bhandari 12

Responsibility of Management Non Clinical standards in this category are set with the following intention a The standards encourage the governance of the Dental Practice in a professional and ethical manner b The responsibilities of the management are defined c The Dental Practice complies with all applicable regulations d The Dental Practice is led by a suitably qualified and experienced individual e The responsibilities of the leaders at all levels are defined f The services provided by each department are documented g Dental Practice ensure that patient safety and risk management issues are an integral part of patient care and hospital management Dental Business Masters Dr Sameer Bhandari 13

Facility Management Safety Non Clinical standards in this category are set with the following intention a The standards guide the provision of a safe and secure environment for patients their families staff and visitors b The Dental Practice shall take steps to ensure this c To ensure this the Dental Practice conducts regular facility inspection rounds and takes the appropriate action to ensure safety d The Dental Practice provides for safe water electricity medical gases and vacuum systems e The Dental Practice has a programme for clinical and support service equipment management f The Dental Practice plans for emergencies within the facilities and the community g The Dental Practice is a no smoking area and manages hazardous materials in a safe manner Dental Business Masters Dr Sameer Bhandari 14

Human Resource Management Non Clinical standards in this category are set with the following intention a The most important resource of a hospital and health care system is the human resource b Human resources are an asset for effective and efficient functioning of a hospital c Without an equally effective human resource management system all other inputs like technology infrastructure and finances come to naught d Human resource management is concerned with the people dimension in management e The goal of human resource management is to acquire provide retain and maintain competent people in right numbers to meet the needs of the patients and community served by the Dental Practice f This is based on the Dental Practice s mission objectives goals and scope of services Dental Business Masters Dr Sameer Bhandari 15

g Effective Human Resource Management involves the following processes and activities a Acquisition of Human Resources which involves human resource planning recruiting and socialization of new employees b Training and development relates to the performance in the present and future anticipated jobs The employees are provided with opportunities to advance personally as well as professionally c Motivation relates to job design performance appraisal and discipline d Maintenance relates to safety and health of the employees h The term employee refers to all salaried personnel working in the DENTAL PRACTICE i The term staff refers to all personnel working in the Dental Practice including employees fee for service medical professionals part time workers contractual personnel and volunteers Dental Business Masters Dr Sameer Bhandari 16

Information Management systems Non Clinical standards in this category are set with the following intention a Information is an important resource for effective and efficient delivery of health care b Provision of health care and its continued improvement is dependent to a large extent on the information generated stored and utilized appropriately by the Dental Practice s One of the major Intent of this chapter is to ensure data and information meet the Dental Practice s needs and support the delivery of quality care and service c Provision of patient care is a complex activity that is highly dependent on communication of information d This communication is to and from the community patients and their families and other health professionals e Failures in communication are one of the most common root causes of patient safety incidents f The goal of Information management in a hospital is to ensure that the right information is made available to the right person Dental Business Masters Dr Sameer Bhandari 17

g This is provided in an authenticated secure and accurate manner at the right time and place h This helps to achieve the ultimate Dental Practice goal of a satisfied and improved provider and recipient of any health care setting i An effective Information management system is based on the information needs of the Dental Practice The system is able to capture transmit store analyse utilize and retrieve information as and when required for improving clinical outcomes as well as individual and overall Dental Practice s performance j Although a digital based information system improves efficiency the basic principles of a good information management system apply equally to a manual paper based system k These standards are designed to be equally compatible with non computerized systems and future technologies Dental Business Masters Dr Sameer Bhandari 18

Step 1 Compile your Documents ACCREDITATION IS NOTHING BUT A RECOGNATION OF SAFE YET AN EXCEPTIONAL QUALITY OF CARE TO THE PATIENTS BY THE REGULATORY AUTHORTIES DOCUMENTATION EVIDENCE IS THE KEY TO THE ENTIRE PROCESS OF ACCREDITATION SO WHY TO WASTE TIME START COMPILING ALL THE NECESSARY LEGAL DOCUMENTS OF YOUR PRACTICE WHICH ALLOW TO RENDER HEALTHCARE TO YOUR PATIENTS IN A LEGITIMATELY DEPENDABLE ENVIRONMENT ____________________________________ ____ Step No 2 Create a Patient Journey A well crafted patient journey will help you to deliver an Exceptional quality of care always It will create a WOW Experience to the patient It will help you to create a loyal patient for your Practice Dental Business Masters Dr Sameer Bhandari 21

Step No 3 Reorganize your Infrastructure Reorganize infrastructure in your Dental Practice that allows you to create accomplish a perfect patient journey in your practice This patient journey should confirm to the Step No 4 Create a policy for every aspect of patient care A well defined policy for every aspect of patient care will ensures efficient and responsible patient care Patients will understand the Efforts that your Practice take to render the unmatched quality of care You will be the preferred Dental Practice in the vicinity You will earn more loyal Patients Dental Business Masters Dr Sameer Bhandari 22

Step No 5 Create a Standard Operating Protocol for Each procedure Benefits of having SOPs Positive impact on patient care Reduce diagnostic planning procedural discrepancies Generating a quantifiable and accountable data Improved communication between healthcare professionals Improved multidisciplinary work Improved Documentation Step No 6 Manage your Human Resources Managing human resources effectively will not only help your organization but it will help them to perform passionately towards exceptional patient care It will help you to impose responsibility and accountability on them Dental Business Masters Dr Sameer Bhandari 23

Key to Success is to perform Step No 7 Implementation If you implement the policies that you have designed you will be able to Deliver what you envisage Operate effortlessly You will render the Best Quality of Care to your patients Step No 8 Ensure extensive Documentation Extensive Documentation will help you to collect extensive data about your own Practice Analysis of the data will help you to find and fill the lacunae in your Dental Practice Dental Business Masters Dr Sameer Bhandari 24

Step No 9 Auditing Improvising Quality Audits will help you to timely identify the flaws in the system It will also lay down a pathway for the further enhancement in the Quality of Care Step No 10 Become an Accredited Dental Practice You are almost there to apply and practice world class Quality Standards in your Practice We are here to keep you motivated and take you along Join in to keep moving on to the exciting Accreditation Journey Because healthcare Can t Be Compromised Dental Business Masters Dr Sameer Bhandari 25